Rigidity, dyskinesia and other atypical overdose presentations observed at a supervised injection site, Vancouver, Canada

Objective: In midst of the overdose crisis, the clinical features of opioid overdoses seem to be changing. Understanding of the adverse effects of synthetic opioids such as fentanyl is currently limited to clinical settings. Insite, a supervised injection site in Vancouver, Canada, provides an opportunity to better understand illicit drug overdose presentations. Methods: A review of clinical records at Insite for October 2016 to April 2017 was undertaken to quantify atypical overdose presentations. Overdose reports were reviewed for the number of atypical opioid overdose presentations, temporal trends over the study period, concurrent symptoms, and interventions employed by staff. Results: Insite staff responded to 1581 overdoses during the study period, including 497 (31.4%) that did not fit a typical presentation for opioid overdoses. Of these, 485 fit into five categories of atypical features: muscle rigidity, dyskinesia, slow or irregular heart rate, confusion, and anisocoria. Muscle rigidity was the most common atypical presentation, observed in 240 (15.2%) of the overdose cases, followed by dyskinesia, observed in 150 (9.2%). Slow or irregular heart rate was observed in 69 (4.4%) cases, confusion in 24 (1.5%), and anisocoria in 2 (0.1%) of overall overdose cases. Discussion: The similarity of atypical overdose cases at Insite with anesthesiology case reports supports the understanding that the illicit drug supply is contaminated by fentanyl and other synthetic opioids. Atypical overdose presentations can affect clinical overdose response. The experience at Insite highlights the potential for supervised consumption sites to be innovative spaces for community learning and knowledge translation.Medicine, Faculty ofNon UBCPopulation and Public Health (SPPH), School ofReviewedFacult

Evaluation of a fentanyl drug checking service for clients of a supervised injection facility, Vancouver, Canada

Background: British Columbia, Canada, is experiencing a public health emergency related to opioid overdoses driven by consumption of street drugs contaminated with illicitly manufactured fentanyl. This cross-sectional study evaluates a drug checking intervention for the clients of a supervised injection facility (SIF) in Vancouver. Methods: Insite is a facility offering supervised injection services in Vancouver’s Downtown East Side, a community with high levels of injection drug use and associated harms, including overdose deaths. During July 7, 2016, to June 21, 2017, Insite clients were offered an opportunity to check their drugs for fentanyl using a test strip designed to test urine for fentanyl. Results of the drug check were recorded along with information including the substance checked, whether the client intended to dispose of the drug or reduce the dose and whether they experienced an overdose. Logistic regression models were constructed to assess the associations between drug checking results and dose reduction or drug disposal. Crude odds ratios (OR) and 95% confidence intervals (CI) were reported. Results: About 1% of the visits to Insite during the study resulted in a drug check. Out of 1411 drug checks conducted by clients, 1121 (79.8%) were positive for fentanyl. Although most tests were conducted post-consumption, following a positive pre-consumption drug check, 36.3% (n = 142) of participants reported planning to reduce their drug dose while only 11.4% (n = 50) planned to dispose of their drug. While the odds of intended dose reduction among those with a positive drug check was significantly higher than those with a negative result (OR = 9.36; 95% CI 4.25–20.65), no association was observed between drug check results and intended drug disposal (OR = 1.60; 95% CI 0.79–3.26). Among all participants, intended dose reduction was associated with significantly lower odds of overdose (OR = 0.41; 95% CI 0.18–0.89). Conclusions: Although only a small proportion of visits resulted in a drug check, a high proportion (~ 80%) of the drugs checked were contaminated with fentanyl. Drug checking at harm reduction facilities such as SIFs might be a feasible intervention that could contribute to preventing overdoses in the context of the current overdose emergency.Medicine, Faculty ofOther UBCMedicine, Department ofPopulation and Public Health (SPPH), School ofReviewedFacult

Is expected substance type associated with timing of drug checking service utilization?: A cross-sectional study

Background Drug checking is a harm reduction intervention aiming to reduce substance use-related risks by improving drug user knowledge of the composition of unregulated drugs. With increasing fears of fentanyl adulteration in unregulated drugs, this study sought to examine whether the expected type of drug checked (stimulant vs. opioid) was associated with timing of drug checking service utilization (pre-consumption vs. post-consumption). Methods Data were derived from drug checking sites in British Columbia between October 31, 2017 and December 31, 2019. Pearson’s Chi-square test was used to examine the relationship between expected sample type (stimulant vs. opioid) and timing of service utilization. Odds ratios (OR) were calculated to assess the strength of this relationship. The Mantel–Haenszel (MH) test was used to adjust for service location. Results A total of 3561 unique stimulant and opioid samples were eligible for inclusion, including 691 (19.40%) stimulant samples; and 2222 (62.40%) samples that were tested pre-consumption. Results indicated a positive association between testing stimulant samples and testing pre-consumption (OR = 1.45; 95% CI 1.21–1.73). Regions outside of the epicenter of the province’s drug scene showed a stronger association with testing pre-consumption (ORMH = 2.33; 95% CI 1.51–3.56) than inside the epicenter (ORMH = 1.33; 95% CI 1.09–1.63). Conclusion Stimulant samples were more likely to be checked pre-consumption as compared with opioid samples, and stimulant samples were more likely to be tested pre-consumption in regions outside the epicenter of the province’s drug scene. This pattern may reflect a concern for fentanyl-adulterated stimulant drugs.Medicine, Faculty ofMedicine, Department ofPopulation and Public Health (SPPH), School ofReviewedFacultyResearche

Characterizing the presence of fentanyl analogues in the unregulated drug supply in British Columbia, Canada

Background: The emergence of fentanyl and its analogues (e.g., carfentanil) have contributed to a rise in overdose-related mortality. The objective of this study was to describe samples containing fentanyl analogues appearing in the unregulated drug supply of British Columbia (BC), Canada. Methods: Point-of-care drug checking data, using a combination of fentanyl immunoassay strips and Fourier-transform infrared spectroscopy (FTIR), were collected at harm reduction sites in BC between 2017 and 2021. A subset of samples were sent for confirmatory analysis using quantitative nuclear resonance spectroscopy, gas chromatography-mass spectrometry, and/or liquid chromatography-mass spectrometry. Results: A total of 22916 samples were tested using point of care technologies, with 43% testing positive for fentanyl via fentanyl test strips. 1467 were sent for confirmatory analysis, and of these 854 (58%) tested positive for fentanyl via fentanyl test strips and 84 (6%) contained at least one fentanyl analogue, including: carfentanil (n=61), acetyl fentanyl (n=15), furanyl fentanyl (n=8) and cyclopropyl fentanyl (n=5). Fourteen (16%) samples containing a fentanyl analogue tested negative via fentanyl immunoassay strips and fentanyl was also not detected using FTIR. Fentanyl analogues in all fourteen samples were identified in trace amounts via confirmatory analysis. Conclusion: Fentanyl analogues were present in the unregulated drug supply and while the risk profiles are known for some, not all are well characterized. These findings underscore the importance of drug checking initiatives for monitoring the unregulated drug market.Medicine, Faculty ofNon UBCMedicine, Department ofPathology and Laboratory Medicine, Department ofPopulation and Public Health (SPPH), School ofUnreviewedFacultyResearche

Enhanced surveillance to monitor response to a provincial overdose emergency, Canada

ObjectiveTo describe the use of multiple data sources to monitor overdoses in near real-time in order to evaluate response to the provincial overdose emergencyIntroductionOn April 14, 2016, British Columbia (BC)’s Provincial Health Officer declared a public health emergency due to a significant increase in drug-related overdoses and deaths in the Province. Despite the declaration, 161 suspected drug overdose deaths were reported across the Province in December 2016, a 137% increase over the number of deaths occurring in the same month of 2015 [1]. In response to the surge overdoses, Vancouver Coastal Health Authority (VCH), one of 5 health regions within BC, rapidly implemented a number of novel harm reduction initiatives. Overdose Prevention Sites (OPS) were opened on December 8, 2016. At these sites, people using illicit drugs are supervised by peers who can provide rapid intervention if an overdose occurs. The Mobile Medical Unit (MMU), a temporary state-of-art medical facility, was deployed on December 13, 2016 to reduce the congestion for the BC Ambulance Service (BCAS) and a major urban emergency department (ED) [2]. Following deployment of the MMU, services were transitioned to a permanent program at the Downtown Eastside Connections Clinic (DTES Connections) in the spring of 2017. DTES Connections was created to provide rapid access to addiction treatment [3]. In order to keep pace with the rapidly increasing number of novel harm reduction initiatives, enhanced surveillance programs were implemented at VCH to monitor and evaluate these innovative harm reduction activities, including development of new surveillance programs for the MMU, OPS and DTES Connections, along with existing routine surveillance system from EDs and a Supervised Injection Site (Insite).MethodsSince 2011, after a spike of heroin-related deaths was reported in the Vancouver region, VCH started weekly monitoring of overdoses at nine EDs and Insite. Daily data extracts from EDs are automatically transferred to a secure driver by secure file transfer protocols. Groups of ICD 9/10 codes and keywords were refined to identify overdoses from EDs. A formal epidemiological evaluation was conducted to measure the algorithm’s accuracy in 2013. A live connection with Insite database was set up in 2011. Overdose events at Insite are clinically determined by clinical staff. Substance injected, characteristics of overdose event and emergency interventions are entered in the database.With the implementation of MMU, OPS and DTES Connections, a series of protocols were developed to monitor visitors' information and overdose events from each site. Demographic information, visit information, clinical presentations and substance used are collected from MMU and DTES Connections. A subset of data fields, including client handle, visit information, substance involved, overdose occurrence, naloxone intervention and ED transfer, are collected from OPS to minimize impact on peers and community partners who run the sites.ResultsBetween November 2016 and January 2017, a sharp increase in overdoses was identified from EDs and Insite. Opioids, especially fentanyl and analogs, most likely contributed to the sudden increase. Weeks with government income assistance payment showed an even greater increase in overdoses.Since December 2016, six OPS opened in Vancouver. Four of them are still operating and one received federal approval to become a supervised consumption site. By September 2017, there were 184,760 visits to the OPS. 1,017 overdoses were reversed.A total of 2,798 patients visited the MMU during the whole operation period. 589 (21%) presented from treatment of overdose. The highest number of overdose visits occurred on December 21, 2016 after that month’s income assistance payment. Since then, the number of visits fluctuated with most visits driven by non-overdose related reasons. 89% of overdose visits arrived by BCAS and 79% of overdoses needed emergent and urgent care.108 patients were transferred to DTES Connections by BCAS for treatment of overdoses by September 2017. All patients presented with opioid addiction issues.As of the end of September 2017, no deaths were reported from OPS, MMU and DTES Connections since operations.ConclusionsAs VCH continues responding to the drug overdose emergency in face of increasing drug overdoses, enhanced surveillance data have been widely used by the VCH Emergency Overdose Response Committee for decision making on harm reduction activities, such as expanding operation hours at OPS and Insite on income assistance payment days; examining the impact on EDs of opening the MMU; encouraging users to avoid using alone; opening new supervised injection service and women’s only OPS; and referring ED patients with non-fatal overdose to rapid access opioid agonist treatment and outreach follow-up

Take-home drug checking as a novel harm reduction strategy in British Columbia, Canada.

BACKGROUND: Drug checking is a harm reduction strategy used to identify components of illicitly obtained drugs, including adulterants, to prevent overdose. This study evaluated the distribution of take-home fentanyl test strips to people who use drugs (PWUD) in British Columbia, Canada. The primary aim was to assess if the detection of fentanyl in opioid samples was concordant between a take-home model and testing by trained drug checking staff. METHODS: Take-home fentanyl test strips were distributed at ten sites providing drug checking services from April to July 2019. The fentanyl positivity of the aggregate take-home and on-site drug checking groups were compared by class of substance tested. An administered survey assessed acceptability and behaviour change. RESULTS: 1680 take-home results were obtained from 218 unique participants; 68% of samples (n=1142) were identified as opioids and 23% (n=382) were stimulant samples. During this period, 852 samples were tested using on-site drug checking. The fentanyl positivity of opioid samples was 90.0% for take-home samples and 89.1% for on-site samples (Difference 0.8% (95% CI -2.3% to 3.9%)). These results were not affected by previous experience with test strips. Fentanyl positivity of stimulants in the take-home group was higher than on-site (24.7% vs. 3.2%), but the study was underpowered to conduct statistical analysis on this sub-group. When fentanyl was detected, 27% of individuals reported behaviour change that was considered safer/positive. Greater than 95% of participants stated they would use fentanyl test strips again. CONCLUSIONS: Take-home fentanyl test strips used by PWUD on opioid samples can provide similar results to formal drug checking services and are a viable addition to existing overdose prevention strategies. Use of this strategy for detection of fentanyl in stimulant samples requires further evaluation. This intervention was well accepted and in some participants was associated with positive behaviour change

Factors associated with drug checking service utilization among people who use drugs in a Canadian setting

Background: The United States and Canada are amidst an opioid overdose crisis, with the Canadian province of British Columbia (BC) among the hardest hit. In response, drug checking services (DCS) have been introduced in this setting as a novel pilot harm reduction intervention though little is known about usage rates. Therefore, we sought to identify factors associated with drug checking uptake among people who use drugs (PWUD) in Vancouver, BC. Methods: Data were derived from three ongoing prospective cohort studies of PWUD in Vancouver between June and November 2018. Multivariable logistic regression was used to determine factors associated with self-reported DCS utilization in the past 6 months among participants at high risk of fentanyl exposure (i.e., those self-reporting illicit opioid use or testing positive for fentanyl via urine drug screen). Results: Among 828 eligible participants, including 451 (55%) males, 176 (21%) reported recent use of DCS. In multivariable analyses, factors significantly associated with DCS utilization included: homelessness (Adjusted Odds Ratio [AOR] 1.47; 95% Confidence Interval [CI] 1.01–2.13) and involvement in drug dealing (AOR 1.59; 95% CI 1.05–2.39). Conclusions: In our sample of PWUD, uptake of DCS was low, although those who were homeless, a sub-population known to be at a heightened risk of overdose, were more likely to use the services. Those involved in drug dealing were also more likely to use the services, which may imply potential for improving drug market safety. Further evaluation of drug checking is warranted.Medicine, Faculty ofOther UBCNon UBCPopulation and Public Health (SPPH), School ofReviewedFacult

High willingness to use rapid fentanyl test strips among young adults who use drugs

Background: Synthetic opioid overdose mortality among young adults has risen more than 300% in the USA since 2013, primarily due to the contamination of heroin and other drugs with illicitly manufactured fentanyl. Rapid test strips, which can be used to detect the presence of fentanyl in drug samples (before use) or urine (after use), may help inform people about their exposure risk. The purpose of this study was to determine whether young adults who use drugs were willing to use rapid test strips as a harm reduction intervention to prevent overdose. We hypothesized that those who had ever overdosed would be more willing to use the test strips. Methods: We recruited a convenience sample of young adults who use drugs in Rhode Island from May to September 2017. Eligible participants (aged 18 to 35 with past 30-day drug use) completed an interviewer-administered survey. The survey assessed participant’s socio-demographic and behavioral characteristics, overdose risk, as well as suspected fentanyl exposure, and willingness to use take-home rapid test strips to detect fentanyl contamination in drugs or urine. Participants were then trained to use the test strips and were given ten to take home. Results: Among 93 eligible participants, the mean age was 27 years (SD = 4.8), 56% (n = 52) of participants were male, and 56% (n = 52) were white. Over one third (n = 34, 37%) had a prior overdose. The vast majority (n = 86, 92%) of participants wanted to know if there was fentanyl in their drug supply prior to their use. Sixty-five (70%) participants reported concern that their drugs were contaminated with fentanyl. After the brief training, nearly all participants (n = 88, 95%) reported that they planned to use the test strips. Conclusions: More than 90% of participants reported willingness to use rapid test strips regardless of having ever overdosed, suggesting that rapid fentanyl testing is an acceptable harm reduction intervention among young people who use drugs in Rhode Island. Study follow-up is ongoing to determine whether, how, and under what circumstances participants used the rapid test strips and if a positive result contributed to changes in overdose risk behavior.Medicine, Faculty ofOther UBCNon UBCPopulation and Public Health (SPPH), School ofReviewedFacult

Projected local rain events due to climate change and the impacts on waterborne diseases in Vancouver, British Columbia, Canada

Background: Climate change is increasing the number and intensity of extreme weather events in many parts of the world. Precipitation extremes have been linked to both outbreaks and sporadic cases of waterborne illness. We have previously shown a link between heavy rain and turbidity to population-level risk of sporadic cryptosporidiosis and giardiasis in a major Canadian urban population. The risk increased with 30 or more dry days in the 60 days preceding the week of extreme rain. The goal of this study was to investigate the change in cryptosporidiosis and giardiasis risk due to climate change, primarily change in extreme precipitation. Methods: Cases of cryptosporidiosis and giardiasis were extracted from a reportable disease system (1997–2009). We used distributed lag non-linear Poisson regression models and projections of the exposure-outcome relationship to estimate future illness (2020–2099). The climate projections are derived from twelve statistically downscaled regional climate models. Relative Concentration Pathway 8.5 was used to project precipitation derived from daily gridded weather observation data (~ 6 × 10 km resolution) covering the central of three adjacent watersheds serving metropolitan Vancouver for the 2020s, 2040s, 2060s and 2080s. Results: Precipitation is predicted to steadily increase in these watersheds during the wet season (Oct. -Mar.) and decrease in other parts of the year up through the 2080s. More weeks with extreme rain (>90th percentile) are expected. These weeks are predicted to increase the annual rates of cryptosporidiosis and giardiasis by approximately 16% by the 2080s corresponding to an increase of 55–136 additional cases per year depending upon the climate model used. The predicted increase in the number of waterborne illness cases are during the wet months. The range in future projections compared to historical monthly case counts typically differed by 10–20% across climate models but the direction of change was consistent for all models. Discussion: If new water filtration measures had not been implemented in our study area in 2010–2015, the risk of cryptosporidiosis and giardiasis would have been expected to increase with climate change, particularly precipitation changes. In addition to the predicted increase in the frequency and intensity of extreme precipitation events, the frequency and length of wet and dry spells could also affect the risk of waterborne diseases as we observed in the historical period. These findings add to the growing evidence regarding the need to prepare water systems to manage and become resilient to climate change-related health risks.Medicine, Faculty ofNon UBCPopulation and Public Health (SPPH), School ofReviewedFacult

The British Columbia Drug Overdose and Alert Partnership: interpreting and sharing timely illicit drug information to reduce harms.

Illicit drug overdose is a public health issue that leads to significant morbidity and mortality. In order to reduce the harm associated with substance use, emergent issues related to substances and substance use must be addressed in a timely manner, which requires inter-sectoral collaboration. We describe the British Columbia Drug Overdose and Alert Partnership, an innovative collaborative model of stakeholders who work in prevention, harm reduction, treatment and enforcement related to psychoactive substance use. We describe the formation, purpose, stakeholders, and operation of the partnership and resultant public health surveillance system. We use the example of fentanyl-associated overdoses and deaths to describe the attributes that make the system effective. These include timeliness, flexibility, acceptability and costs. This model of inter-sectoral collaboration and surveillance can be applied to other organizations involved in assessing and responding to drug-related harms